Blowing the whistle during the first wave of COVID‐19: A case study of Quebec nurses

Abstract The experiences of nurses who blew the whistle during the COVID‐19 pandemic have exposed gaps and revealed an urgent need to revisit our understanding of whistleblowing. Aim The aim was to develop a better understanding of whistleblowing during a pandemic by using the experiences and lessons learned of Quebec nurses who blew the whistle during the first wave of COVID‐19 as a case study. More specifically, to explore why and how nurses blew the whistle, what types of wrongdoing triggered their decision to do so and how context shaped the whistleblowing process as well as its consequences (including perceived consequences). Design The study followed a single‐case study design with three embedded units of analysis. Methods We used content analysis to analyse 83 news stories and 597 forms posted on a whistleblowing online platform. We also conducted 15 semi‐structured interviews with nurses and analysed this data using a thematic analysis approach. Finally, we triangulated the findings. Results We identified five themes across the case study. (1) During the first wave of COVID‐19, Quebec nurses experienced a shifting sense of loyalty and relationship to workplace culture. (2) They witnessed exceedingly high numbers of intersecting wrongdoings amplified by mismanagement and long‐standing issues. (3) They reported a lack of trust and transparency; thus, a need for external whistleblowing. (4) They used whistleblowing to reclaim their rights (notably, the right to speak) and build collective solidarity. (5) Finally, they saw whistleblowing as an act of moral courage in the face of a system in crisis. Together, these themes elucidate why and how nurse whistleblowing is different in pandemic times. Conclusion Our findings offer a more nuanced understanding of nurse whistleblowing and address important gaps in knowledge. They also highlight the need to rethink external whistleblowing, develop whistleblowing tools and advocate for whistleblowing protection. Impact In many ways, the COVID‐19 pandemic has challenged our foundational understanding of whistleblowing and, as a result, it has limited the usefulness of existing literature on the topic for reasons that will be brought to light in this paper. We believe that studying the uniqueness of whistleblowing during a pandemic can address this gap by describing why and how health care workers blow the whistle during a pandemic and situating this experience within a broader social, political, organizational context.


| INTRODUC TI ON
During the first wave of the COVID-19 pandemic, defined as March to August 2020, Canada recorded 138,010 cases of COVID-19 and close to 10,000 deaths (CPHA, 2021). The first wave had a devastating impact across the country, but not all jurisdictions were impacted equally (Flood et al., 2020). The province of Quebec, which is the second most populated province in the country and is home to approximately 22% of Canadians (Statistic Canada, 2021), was hit particularly hard during the first 5 months of the COVID-19 pandemic.
By the end of May 2020, for example, the province had recorded 45,773 COVID-19 cases, accounting for 57% of all cases in the country (CPHA, 2021). By the end of July 2020, it had recorded close to 60,000 cases (INESSS, 2020). Of these cases, 14,191 (24%) were amongst health care workers (INESSS, 2020). It also recorded 5820 deaths, primarily in long-term care (INESSS, 2020). Those deaths accounted for 65% of all COVID-19-related deaths in the country and were substantially higher than those recorded in other highincome countries, including the United States (Urrutia et al., 2021).
Because COVID-19 disproportionately affected Quebec during the first wave, the province has been described as a 'textbook case' to study the COVID-19 pandemic and government responses (Alami et al., 2021, p. 2). It also offers a real-world case study of whistleblowing by health care workers during a pandemic and, more specifically, nurses working at the frontline.

| BACKG ROU N D
The classic definition of whistleblowing is the one proposed by Near and Miceli (1985). The authors define whistleblowing as 'a process involving at least four elements: (1) the whistleblower: a former or current member of an organization who is aware of wrongdoing but generally lacks the authority or power to make the required changes; (2) the whistleblowing act: the act of disclosing an illegal, immoral, illegitimate practice to persons or organizations that may be able to bring about change; (3) the complaint receiver: a third party (external whistleblowing) or someone other than or in addition to the immediate supervisor (internal whistleblowing); (4) the organization: a public or private organization who is the target of the whistleblowing and who will be called upon to respond (or not) to the disclosure of wrongdoing' (Gagnon & Perron, 2020a, p. 381). Whistleblowing may appear to challenge to the authority structure of an organization, but it is not an act of deviance or a breach of loyalty per se; it is triggered by the seriousness of the wrongdoing and can indeed offer valuable information to improve organizational effectiveness and public safety .
In the health sciences literature, much of the research focuses on the whistleblower (i.e. motivations, decision-making processes, consequences of whistleblowing and so forth) and, to a lesser extent, on the context in which whistleblowing occurs and the process of whistleblowing itself . The literature also takes as its starting point the experience of employees who witness wrongdoings in the workplace and disclose such wrongdoings internally or externally to the organization after careful ethical deliberation and weighing-in of potential risks and consequences . Nurses (and, to a lesser extent, nursing students) are the most studied health care workers in the whistleblowing literature (Mannion et al., 2018). We attribute this to the nature of nursing practice in care settings and nurses' extensive presence at the 'bedside.' Nurses also constitute the largest group of health care workers in the health care system, which increases their likelihood of witnessing serious risks or patterns of wrongdoings that may trigger a duty to act. Finally, they make up the frontline of the health care system, meaning that, in the event of a pandemic, they bear witness to the policy and management failures, the injustices and the toll these take on patients, families and other workers.
The nursing research on whistleblowing suggests that when nurses blow the whistle, they do so primarily out of concerns for patient care and outcomes (Jackson et al., 2014). Studies conducted to date have identified five types of situations that may result in whistleblowing: (1) unsafe working conditions, (2) deviations from practice standards; (3) unprofessional and harmful behaviours; (4) failure to uphold external whistleblowing, develop whistleblowing tools and advocate for whistleblowing protection. Impact: In many ways, the COVID-19 pandemic has challenged our foundational understanding of whistleblowing and, as a result, it has limited the usefulness of existing literature on the topic for reasons that will be brought to light in this paper. We believe that studying the uniqueness of whistleblowing during a pandemic can address this gap by describing why and how health care workers blow the whistle during a pandemic and situating this experience within a broader social, political, organizational context.

K E Y W O R D S
case study, ethics,nurses,pandemic,qualitative,Quebec,whistleblower,whistleblowing patients' rights and (5) management and organizational issues . Nurses who sound the alarm in such situations are typically employees and they work within a particular organizational context that shapes their beliefs and values, decision-making process, disclosure strategies and overall experience Jackson et al., 2010aJackson et al., , 2010bJackson et al., , 2011Jackson et al., , 2014Mansbach & Bachner, 2010;McDonald & Ahern, 2000Peters et al., 2011;Pohjanoksa et al., 2019ab). With regard to internal and external whistleblowing, recent studies by Pohjanoksa et al. (2019ab) suggest that whistleblowing trajectories are far more complex and messier than traditionally represented. One finding that is consistently noted across the nursing literature, however, is that nurses are more willing to blow the whistle internally (i.e. to follow the chain of command) (Pohjanoksaet al., 2019ab).
In many ways, the COVID-19 pandemic has challenged foundational understandings of whistleblowing because it unfolded on a global scale, across technologically mediated societies, and at a time where health care workers are more connected than ever. Health care workers turned to online platforms, such as ProMED and Twitter, to sound the alarm in the early days of the pandemic (Lopreite et al., 2021;Wark, 2021) and leveraged social media tools to communicate to the public, warn decision-makers, support each other and share testimonials as the pandemic was unfolding Glasdam et al., 2022). Health care workers also faced challenging working conditions compounded by a lack of personal protective equipment (Amon, 2020). They also witnessed and experienced the first-hand impact of COVID-19 policies, generating unprecedented moral distress and injury (Riedel et al., 2022). As a result, growing numbers of health care workers became whistleblowers and many faced reprisals for their actions (Amon, 2020). We believe that studying the uniqueness of whistleblowing during the COVID-19 pandemic can address existing conceptual and empirical gaps by describing why (e.g. what types of wrongdoings, what motivations and to what ends) and how (e.g. nature of the process, steps followed, tools used) health care workers blow the whistle during a pandemic and situating this experience within a broader social, political, organizational context. Quebec nurses constitute a novel case study to understand the experiences of nurses who blew the whistle during the COVID-19 pandemic and identify key takeaways for decision-makers, researchers, clinicians and nursing unions worldwide. The experience of Dr.
Li Wenliang, the original COVID-19 whistleblower who sounded the alarm on the Chinese messaging platform WeChat on 30 December 2019 and later died of COVID-19 (Nie & Elliott, 2020;Zhu, 2020), serves as a strong reminder that whistleblowing in health care is not geographically bounded and that any effort to study the experience of whistleblowers during the pandemic is an opportunity to better support and protect health care workers. As such, the purpose of this paper is to present the findings of a case study that provides insights into the experiences of nurses who blew the whistle and offers potential avenues for improving supports to nurses moving forward.

| Aim
The aim was to develop a better understanding of whistleblowing during a pandemic by using the experiences and lessons learned of Quebec nurses who blew the whistle during the first wave of COVID-19 as a case study. More specifically, to explore why and how nurses blew the whistle, what types of wrongdoing triggered their decision to do so and how context shaped the whistleblowing process as well as its consequences (including perceived consequences).

| Design
We used a case study design as defined by Stake (2005) and Yin (2018) for two main reasons: Quebec's unique and dire context during the first wave of the pandemic and the exertive ways in which nurses engaged in acts of whistleblowing before and during COVID-19. More specifically, we opted for a single-case study design with three embedded units of analysis: news stories, online forms and semi-structured interviews (see Figure 1). This design is appropriate when the selected case is unusual yet representative of a shared experience (i.e. blowing F I G U R E 1 Case study. the whistle during a pandemic), and it has the potential to make a new and significant contribution to knowledge development (Stake, 2005;Yin, 2018). As such, the goal of single-case studies is not to generalize from a single case but rather to conduct an in-depth analysis of the selected case because it has the potential to reveal something new about a phenomenon (Stake, 2005;Yin, 2018). Consistent with singlecase studies, we completed the data collection and analysis for each embedded unit sequentially and then triangulated the three units to build a case description (Yin, 2018). We approached triangulation from an interpretive stance and included multiple data units to add 'rigor, breadth, complexity, richness and depth', not as a means of validation (Denzin, 2012, p. 82). In other words, we used triangulation 'as an attempt to secure an in-depth understanding of the phenomenon in question' (Denzin, 2012, p. 82).

| Data collection
Our single-case study included three embedded units.
The first unit consisted of news stories published in Canadian media during the first wave of the pandemic. We completed our search using the Google Advanced Search operator, which provides the options of using and combining keywords, as well as limiting the search to a specific country (in this case, Canada) and specific dates (January-May 2020). We included the months of January and February because nurses were already blowing the whistle about pandemic preparedness and early response (before the first case of COVID-19 was confirmed in Canada). We described our complete search strategy elsewhere . After screening our initial sample of 119 news stories and eliminating duplicates, we included 83 news stories . Finally, the third unit consisted of semi-structured interviews conducted with Quebec nurses (September-December 2020).
Nurses were recruited using e-cards shared on social media and within existing professional networks. Participants were eligible to take part in this study if they: identified as a nurse (i.e. registered nurse, nurse practitioner or licensed practical nurse), practiced in Quebec during the first wave of the COVID-19 pandemic and had a least one experience of whistleblowing during this period.
Interviews were conducted in French or English, they lasted on average 60 min and were structured to cover four main domains.
Each interview started by asking participants to describe their experience(s) of whistleblowing, including the type of wrongdoing(s), the people involved, the context and circumstances, the decisionmaking process (including reasons motivating the decision and deliberation involved, if any), the whistleblowing process (including strategies used, reasons for using them and issues encountered) and the outcomes. Then, we asked about the organizational context, and more specifically about the organizational culture and how it shaped the whistleblowing process and the experience(s) more broadly.
We also asked about the consequences of the whistleblowing, in-

| Ethical considerations
News stories and online forms, both publicly accessible, did not re-

| Data analysis
Each unit of analysis was analysed separately using a 'ground up' approach (Yin, 2018) and sequentially, and then triangulated to generate the findings presented in this paper.
We analysed the news stories using a content analysis approach, which is particularly useful when working with large amounts of textual data (Hsiu-Hsieh & Shannon, 2005;Schreier, 2014 We also used a content analysis approach to work through the online forms. However, given the size of the data set, we opted for a blend of inductive and deductive analysis. First, 50 randomly selected forms were analysed inductively to create a preliminary thematic structure. Then, 20 additional forms were analysed to 'test' our thematic structure, add emerging themes or combine existing themes. Using 10 additional forms, we confirmed there were no new themes and then worked through the rest of the data set by organizing it according to the thematic structure and frequency . Interviews were analysed using Applied Thematic Analysis (ATA) (Guest et al., 2011). ATA involves four general steps: (1) read and code transcriptions, (2) identify possible themes, (3) compare and contrast themes, identifying structure amongst them and (4) produce a thematic scheme to describe the research phenomenon. We coded five interviews to identify broad themes that were then compared and contrasted as we analysed more interviews. These final organizing themes included: (1) Who is speaking (the whistleblower), (2) Where are they located (relationship to space and place), (3) What are they reporting (types of wrongdoings), (4) How are they reporting, using what strategies and why (whistleblowing process) and (5) What consequences of whistleblowing, real or perceived, do they describe (types of consequences).
Once the thematic analysis was completed, we moved to the final step in case study research: merging all three units to develop a case description (Yin, 2018). Case descriptions are particularly useful to descriptive case studies designed to offer new insights into a phenomenon and identify explanations that merit further exploration. Our case description sought to answer the following question: What can we learn from the experiences of Quebec nurses about the phenomenon of 'whistleblowing during a pandemic'? To answer this question, we triangulated the three units to look for patterns and elements of explanations (Yin, 2018).

| Rigour
We used a number of strategies to ensure rigour. Prior to conducting the study, we reviewed the literature and completed a concept analysis of whistleblowing in nursing . We selected a case that meets the criteria for case study research and used multiple sources of data to gain a more in-depth understanding the case (Yin, 2018). We maintained credibility by triangulating three units of analysis and maintaining prolonged engagement in the field (Houghton et al., 2013). We provided a rich description of the context to situate our findings and kept an audit trail of our process.
Finally, we presented and discussed the findings with the aim of maximizing transferability while also pointing out unique elements of the case that other researchers can learn from and potentially use to inform future research.

| News stories
The voices of Quebec nurses were overrepresented in our sample (66%). Of the 83 news stories, 38 (46%) were published in English and 45 (54%) in French. News stories often included both collective and individual voices. Unions were the strongest collective voices in the sample, featured in 55% (n = 46) of the news stories. The FIQ was by far the most active union voice, appearing in more than half of those stories. We found equal numbers of stories in which nurses were identified (with name and picture) and anonymized. The main reason cited for requesting anonymity was the risk of workplace retaliation and sanctions (including job loss) for speaking out in the media.

| Online forms
Our sample exclusively included online forms submitted by nurses.
The online form included the option of entering personal information (i.e. name, title, workplace). However, in the majority of our sample, nurses opted not to disclose such information. The form also included a text box and the option of attaching a document or a picture. Our sample included the text box content of the forms submitted by 597 nurses.

| Interviews
We interviewed 15 nurses, including licensed practical nurses (n = 1) and registered nurses with a college (n = 4) or a university (n = 10) degree. The majority of participants reported practising in a hospital setting (n = 9), while others reported practising in long-term care (n = 4) and home care (n = 2). Out of the 15 participants, 14 self-identified as women. Most participants were 35 years old or less (n = 9). Twelve (80%) participants had been working as a nurse for 10 years or less (6 with 5 years or less of experience, 6 with 5-10 years of experience). Finally, when asked about previous experiences of whistleblowing, half of the participants reported having blown the whistle at least once before COVID-19.

| FIND ING S: THE C A S E
In accordance with case study methodology, our findings will be di-  Quebec entered the pandemic with a weakened nursing workforce whose capacity to handle increased demands, high patient loads and forced overtime was exceedingly jeopardized.
The culture of silence across the health care system was an important factor denounced before the pandemic. This culture favoured the muzzling and disciplining of whistleblowers to the detriment of transparency and organizational change. It is worth recalling that in 2017, the Quebec government implemented the Act to facilitate the disclosure of wrongdoings relating to public bodies.
The main purpose of this law was to protect whistleblowers in the public sector, including in publicly funded health care settings and facilities. However, instead of facilitating whistleblowing, it has been found to provide a narrow pathway for disclosure and impose conditions under which public disclosure can be made-and protection granted. In view of the above, Quebec entered the first wave of the COVID-19 pandemic with a law that did not significantly change the culture of silence in health care, nor did it offer concrete disclosure tools or mechanisms for nurses to use.

| Key themes within the case
We identified five themes across our case (see Figure 2). Together, these themes elucidate why and how nurse whistleblowing is different in pandemic times. While these themes are specific to the case (i.e. whistleblowing amongst Quebec nurses) and the con-  Across our sample, nurses described the Ministerial Order as a blunt instrument that was overused (and abused) in the health care system.
In particular, nurses denounced the fact that the order exacerbated many long-standing issues (e.g. nurse burnout) entrenched by a 20- year legacy of using exceptional measures such as mandatory overtime as a routine management practice rather than addressing deteriorating care environments. As one interview participant explained, Quebec nurses were already frequently working 16-h shifts in mandatory overtime before COVID-19. As one participant noted, following the Ministerial Order: The imposition of mandatory overtime increased a lot. The increase was phenomenal (…) For example, there was one shift where the unit was five nurses short, and they didn't find anyone. All the nurses were forced into overtime, and they all did a 16-h shift.
(Hélène, November 11, 2020) During the interview, Hélène further described an instance of being forced to work 24 consecutive hours and waking up the next day feel-

| Lack of trust and transparency creating a need for external whistleblowing
Nurses engaged in internal whistleblowing or external whistleblowing, or both. Internally, the two main strategies mentioned across the sample were emailing one's superior or using institutional forms such as incident reports. Nurses shared that these strategies were ineffective, and for many, they even resulted in targeted retaliation and sanctions, including reprimand letters and suspensions. Notably, many nurses who wished to sound the alarm internally were unable to find effective means to do so within the organizations where they worked or volunteered. One interview participant, who made multiple attempts to report serious issues internally, summarized it as such: Basically, I realized that not only did official [internal] channels not work but there aren't any, really, like they don't really exist. I asked everyone, "What is the official channel for reporting this [lack of PPE]?" and no one knew. They all said "maybe this or that," but no one was able to tell me (…). It was eye-opening for me. I knew that official channels were like an illusion, that they didn't really work, but then I experienced it. Trying to find them, and they just don't exist.
(Gabriella, October 16, 2020) Data across all three units showed that institutional reporting channels were already deficient or inexistent before the COVID-19 pandemic.
Furthermore, for many nurses, the decision to turn to outside channels was also due to the fact that the issues they needed to report were organizational, making internal reporting channels less safe. sure what they would be really, but I just thought to myself that we're in a free country, and we have the right to speak.
(Josette, 5 November 2020) External whistleblowing also allowed nurses to speak as workers and push back against the predominant 'angel narrative.' Indeed, during the first two waves, the Quebec Premier consistently described nurses as guardian angels during daily briefings, which nurses viewed as a perverse strategy to encourage and normalize nurses' sacrifice. External whistleblowing allowed the production and dissemination of a counternarrative re-centering nurses as human beings and as workers entitled to protection from unsafe working conditions.
They call us guardian angels, but they treat us like Nurses' desire to be seen and treated as human beings was one of the most consistent threads across the sample. It was also a powerful driver of external whistleblowing because it provided an opportunity to represent nurses as health care workers whose inherent dignity and vulnerability to COVID-19 demanded recognition, as opposed to disposable caregivers expected to sacrifice themselves.
We found that efforts to humanize nurses were part of a broader struggle for nurses to reclaim their rights as workers and speak out against governmental and managerial decisions that put their health, lives and families at risk. These included, but were not limited to, being denied COVID-19 testing, being forced to work while symptomatic, being refused workplace accommodations, being placed in high-risk situations (i.e. pregnant nurses, immunocompromised nurses, etc.) and having insufficient/inadequate or no access to adequate PPE. One national media outlet reported a story about a nurse who was denied testing as follows: That he was told after his shift that he had been exposed to a nurse who tested positive for COVID-19.
When he requested testing, "he was denied testing by the hospital." At the time of the interview, he [the nurse] insisted on the importance of "testing every single nurse out there." When asked to comment on the news story, the Quebec Health Minister responded that "testing is a priority," but residents and patients come first.
(Quoted from a video interview, Global News April 16, 2020) Throughout the sample, we noted that external whistleblowing strategies used by nurses had a strong collective focus; that is, when nurses spoke out and spoke up about their individual experiences, they did so in solidarity with other nurses and for their collective rights. As mentioned above, we also found a high number of news stories featuring collective union voices. This is an important finding because whistleblowing tends to be understood exclusively as an individual phenomenon.

| Moral courage in the face of a system in crisis
Our findings suggest that blowing the whistle was experienced and seen as an act of moral courage by nurses. Although slight variations exist in the definition of moral courage, we define it here as the courage a person demonstrates when acting in a way that aligns with their values and beliefs despite fear or threat of negative consequences for the acting individual (Pajakoski et al., 2021).
We use the concept of moral courage to capture the motivations, rationales and intentions cited by nurses across all units. Nurses' decisions and actions were first and foremost motivated by a strong sense of moral and professional obligation to advocate for patients. One nurse who resigned from long-term care after witnessing the deaths of many residents due to COVID-19 spoke to the media after writing a letter to the Premier, the Minister of Health and the Director of Public Health. She explained what motivated this decision and action: We've been screaming for help for a long time. This crisis [the COVID-19 pandemic] exposed the existing flaws in our health care system and how extensive they are. Yes, we [nurses] want to be there and help, but our role as nurses is also to be advocates for our patients. (nurse quoted in a news story published on April 25, 2020) The rationales underpinning nurses' decisions and actions can be divided into three main categories. The first category focuses on the wrongness of the pandemic response and how it created and exacerbated COVID-19-related risks, suffering and deaths. The second category speaks to the need to do the right thing. Nurses were adamant that blowing the whistle, through whatever means necessary, was the right thing to do as nurses because it was in the public's interest, consistent with professional obligations, and a matter of moral integrity. The third category, which emerged clearly and strongly in our data, was the realization on the part of many nurses that they had nothing (or less) to lose and nothing (or less) to fear anymore. Nurses felt that in a system in crisis that desperately needed nurses, they held more power, and they, therefore, assessed the risks of whistleblowing differently than before COVID-19. While most perceived fewer risks, leading them to act without or despite the fear of negative consequences, for some such fear remained and was the main reason for requesting anonymity in media interviews or for resorting to other reporting strategies, such as the FIQ platform, for example.
We're at a point of wanting to quit collectively. Our employer tried to intimidate us recently at a meeting.
One of the nurses got a disciplinary notice yesterday, and she quit on the spot, so the day staff had to do mandatory overtime.
(Online form 571) In addition to the motivations and rationales described above, nurses had clear intentions when they blew the whistle. They were hoping for change, but they were also determined to bring much-needed awareness to the public, the media and the government about pandemic management failures. In order words, they strove to make the invisible visible. This explains why many of our interview participants stated that blowing the whistle gave them a feeling of 'mission accomplished,' regardless of th outcomes. did not perceive a 'clash of loyalty' as is typically described in the literature . This was true for nurses who blew the whistle both as employees and as volunteers. They felt a strong sense of loyalty to the profession, patients and the public, but given widespread managerial abuses and the risks they faced, they did not believe they owed loyalty to employers, institutions and the government. Second, the nature of the wrongdoings witnessed by nurses was managerial and political in nature. This departs from existing literature, which mainly locates wrongdoings within a specific person (e.g. colleague, manager, etc.), workplace or institution. Rarely does the literature on whistleblowing in health care speak to system-level wrongdoings. Third, nurses did not follow the traditional whistleblowing pathway, which typically begins with the nurse using internal reporting channels before resorting to external whistleblowing when they lose trust in internal channels (e.g. following retaliation) and/or determine that these channels are ineffective. Instead, they turned to external whistleblowing far more quickly, hoping for a prompt, more efficient remediation. This has not been documented in the nursing literature to date.

| Rethinking external whistleblowing
Nursing has a complicated relationship with external whistleblowing. At the level of the profession and the discipline, external whistleblowing is typically depicted as a last resort, a risky practice and an act of disclosure that may run counter to professional and contractual duties-thus leaving nurses with little protection and support . This approach to external whistleblowing not only shapes the experiences of nurses who blow the whistle but it also governs how we study and think about those experiences. As a result, the nursing literature tends to focus on the whistleblower's beliefs and values , decision-making process (Jackson et al., 2010a;Pohjanoksa et al., 2019ab) and consequences (Jackson et al., 2010bMcDonald & Ahern, 2000Peters et al., 2011). In other words, research to date focuses on how nurses come to make the 'difficult' decision to blow the whistle, which is assumed to only be ethically justifiable in exceptional circumstances and inherently risky, and on the consequences they may face as a result. Less emphasis has been placed on organizational culture and its role in increasing or reducing the need for external whistleblowing, harming or supporting nurse whistleblowers, problematizing or normalizing disclosures of wrongdoings and so forth Jackson et al., 2014).
Our findings suggest that external whistleblowing is a symptom of a system in crisis, one that triggers an obligation on the part of nurses to speak courageously and openly. They also point to the lack of available alternatives within organizations and nurses' strategic use of technologies to break through a culture of silence that puts patients, nurses and others at risk. Finally, our findings challenge the idea that external whistleblowing always comes at a cost to nurses. We found that the cost of remaining silent can be far greater, especially during a pandemic.  (Brunelle & Samson, 2005;Newham et al., 2021), especially in the context of a pandemic. Our findings

| The role of whistleblowing tools
show that the duty of loyalty of nurses is first and foremost directed towards the patients and the profession. As such, fulfilling their professional duties and protecting patients is more important than maintaining the reputation of their workplaces and employers. This, we argue, is an important part of the social contract between nurses and the public. Our position echoes the recent ruling of the Court of Appeal of Saskatchewan (2020)

| Strengths and limitations
This case study offers a significant contribution to the body of literature on whistleblowing in nursing, and it sheds light on important pandemic-specific considerations that are relevant to decisionmakers, researchers and clinicians. The strengths of our study include the triangulation of three sources of data, the inclusion of a case description to situate the study findings and the selection of a unique case of nurses blowing the whistle with greater intensity than other Canadian provinces through different strategies and one novel, unique whistleblowing tool (the FIQ online platform).
However, some limitations should be considered when interpreting our findings. The study was based in one province and may not reflect the reality of nurses in other jurisdictions. Sociodemographic information was only available for interview participants, which limited our understanding of the profile of nurses who blew the whistle. For example, most of our interview participants tended to be younger with less than ten years of nursing experience. We were not able to explore this further in the case study. Finally, the case study focused exclusively on the first wave of the COVID-19 pandemic.

| CON CLUS ION
Over the course of the COVID-19 pandemic, whistleblowing by nurses and other health care workers has intensified worldwide and has taken a turn outwards because of various governmental, organizational, managerial and technological factors (Amnesty International, 2020). Our case study offers a starting point to understand the experiences of nurses who blow the whistle during a pandemic. We have highlighted the importance of rethinking our understanding of external whistleblowing, developing tools to better support nurses and enacting legislated whistle-blower protections that account for the nature of wrongdoings brought to the forefront during COVID-19. Our findings reframe whistleblowing as a positive action rather than a negative one, one that nurses undertake as professionals committed to the public interest, as members of a collective and as workers endowed with basic, inalienable rights. They also further support a view of whistleblowing as a symptom of much broader problems of transparency and accountability. Addressing these problems is a crucial step towards protecting nurses and, therefore, the patients they care for.

AUTH O R CO NTR I B UTI O N S
This case study was part of a larger study on whistleblowing for which the listed authors received funding (except CD). The case study design was led by MG. MG, AP, EM and CD collected and analysed the case study data: (1) News stories were collected by MG and analysed with AP, (2) Online forms were collected by EM and CD and analysed with MG and AP, (3) Interviews were conducted by MG and CD and analysed with AP. MG triangulated the data and identified the themes. MG wrote the original draft of the manuscript. All authors contributed to reviewing and editing the manuscript.

ACK N OWLED G EM ENTS
We would like to thank the nurses who participated in this study.

This study was supported by the Social Sciences and Humanities
Research Council, Insight Grant (435-2019-1249).

CO N FLI C T O F I NTE R E S T
We declare no competing interests.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15365.

DATA AVA I L A B I L I T Y S TAT E M E N T
News stories and online forms are publicly available. The interviews are not available for confidentiality reasons.